Transphobia rather than education predicts provider knowledge of transgender health care

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/148342/1/medu13796.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/148342/2/medu13796_am.pd

Online Patient Portals: If You Build It, Who Will Come?

Research Objective: Many primary care practices have purchased electronic health records (EHRs) and accompanying patient portals. The role online portals may play in quality and outcome improvement will depend not only on who is using such technology, but how it is used. We evaluate the characteristics of patients using an online portal in comparison to those not using, and examine the portal features and functionalities accessed by users.Study Design: Observational, cohort study for which data were obtained from EHR and health system administrative data. Patient-level data (including demographic information, service use, and portal activation and use) were joined with information characterizing clinics in which patients received care (e.g., medical teaching on site, size, and urban/suburban location). The primary study outcome, portal use, was defined by the initiation of at least one online session. Among users, user-initiated clicks were used to determine specific features accessed. Logistic regression models with random effects were fit using the PROC GLIMMIX procedure (SAS software, Version 9.4) to test the role of clinic- and patient-level variables on patient portal activation. Subjects were blocked by physician, nested within clinic, and the Laplace method was used for likelihood approximation.Population Studied: Study eligible patients were aged 18 years and older with an office visit between 4/1/2013 and 3/31/2014 to a primary care physician practicing in one of the 26 primary care clinics of an integrated delivery system serving Detroit, Michigan and the surrounding suburban areas (N=20,282 patients).Principal Findings: As implemented in December 2012, the online portal enabled users to securely schedule appointments, receive appointment reminders, pay bills online, view lab and other test results, manage information about their health, and communicate with care teams via a secure messaging system. Cohort patients were on average 68.7 years of age (SD=14.7), predominately white (65%) or black (30%) race, and 60% female. Within 18 months of implementation, 33% had an activated account, with African Americans (OR=0.50, 95% CI 0.46-0.56), Hispanics (OR=0.63, 95% CI 0.47-0.84), those over aged 70 years (OR=0.48, 95% CI 0.44-0.52), and those preferring a language other than English (OR=0.43, 95% CI 0.31-0.59) less likely to be a portal user. Patients who were married (OR=0.55, 95% CI 1.44-1.67) and more connected with the clinic, as measured by visit frequency and health maintenance visit use, were more likely to be portal users (OR=1.08, 95% CI 1.05-1.10 and OR=1.39, 95% CI 1.27-1.52, respectively). Among users, the medical record access and management feature (95.9%) was most commonly accessed, most often to obtain laboratory testing results (91.7%). The majority of users also accessed appointment management (76.6%) and messaging (59.1%) functionalitiesConclusions: While the diversity of functions accessed by those with a portal account bodes well for the ability of portals to engage patients, without purposeful intervention enhancements to care delivery afforded by portals may be inaccessible to many, including racial/ethnic minorities and those less connected to traditional care services.Implications for Policy or Practice: Online portals have the potential to extend care beyond the confines of traditional office visits, but inattention to who uses portals may exacerbate known disparities in health care access and outcomes

Randomised Trial to Evaluate the Effectiveness and Impact of Offering Postvisit Decision Support and Assistance in Obtaining Physician-Recommended Colorectal Cancer Screening: The e-Assist: Colon Health Study - A Protocol Study

INTRODUCTION: How to provide practice-integrated decision support to patients remains a challenge. We are testing the effectiveness of a practice-integrated programme targeting patients with a physician recommendation for colorectal cancer (CRC) screening. METHODS AND ANALYSIS: In partnership with healthcare teams, we developed \u27e-assist: Colon Health\u27, a patient-targeted, postvisit CRC screening decision support programme. The programme is housed within an electronic health record (EHR)-embedded patient portal. It leverages a physician screening recommendation as the cue to action and uses the portal to enrol and intervene with patients. Programme content complements patient-physician discussions by encouraging screening, addressing common questions and assisting with barrier removal. For evaluation, we are using a randomised trial in which patients are randomised to receive e-assist: Colon Health or one of two controls (usual care plus or usual care). Trial participants are average-risk, aged 50-75 years, due for CRC screening and received a physician order for stool testing or colonoscopy. Effectiveness will be evaluated by comparing screening use, as documented in the EHR, between trial enrollees in the e-assist: Colon Health and usual care plus (CRC screening information receipt) groups. Secondary outcomes include patient-perceived benefits of, barriers to and support for CRC screening and patient-reported CRC screening intent. The usual care group will be used to estimate screening use without intervention and programme impact at the population level. Differences in outcomes by study arm will be estimated with hierarchical logit models where patients are nested within physicians. ETHICS AND DISSEMINATION: All trial aspects have been approved by the Institutional Review Board of the health system in which the trial is being conducted. We will disseminate findings in diverse scientific venues and will target clinical and quality improvement audiences via other venues. The intervention could serve as a model for filling the gap between physician recommendations and patient action. TRIAL REGISTRATION NUMBER: NCT02798224; Pre-results

Suicide Attempts Among a Cohort of Transgender and Gender Diverse People

INTRODUCTION: Transgender and gender diverse people often face discrimination and may experience disproportionate emotional distress that leads to suicide attempts. Therefore, it is essential to estimate the frequency and potential determinants of suicide attempts among transgender and gender diverse individuals. METHODS: Longitudinal data on 6,327 transgender and gender diverse individuals enrolled in 3 integrated healthcare systems were analyzed to assess suicide attempt rates. Incidence was compared between transmasculine and transfeminine people by age and race/ethnicity and according to mental health status at baseline. Cox proportional hazards models examined rates and predictors of suicide attempts during follow-up. Data were collected in 2016, and analyses were conducted in 2019. RESULTS: During follow-up, 4.8% of transmasculine and 3.0% of transfeminine patients had at least 1 suicide attempt. Suicide attempt rates were more than 7 times higher among patients aged45 years, more than 3 times higher among patients with previous history of suicide ideation or suicide attempts than among those with no such history, and 2-5 times higher among those with 1-2 mental health diagnoses and more than 2 mental health diagnoses at baseline than among those with none. CONCLUSIONS: Among transgender and gender diverse individuals, younger people, people with previous suicidal ideation or attempts, and people with multiple mental health diagnoses are at a higher risk for suicide attempts. Future research should examine the impact of gender-affirming healthcare use on the risk of suicide attempts and identify targets for suicide prevention interventions among transgender and gender diverse people in clinical settings

Discrimination and Delayed Health Care Among Transgender Women and Men: Implications for Improving Medical Education and Health Care Delivery.

BACKGROUND: The transgender community experiences health care discrimination and approximately 1 in 4 transgender people were denied equal treatment in health care settings. Discrimination is one of the many factors significantly associated with health care utilization and delayed care. OBJECTIVES: We assessed factors associated with delayed medical care due to discrimination among transgender patients, and evaluated the relationship between perceived provider knowledge and delayed care using Anderson\u27s behavioral model of health services utilization. RESEARCH DESIGN: Multivariable logistic regression analysis was used to test whether predisposing, enabling, and health system factors were associated with delaying needed care for transgender women and transgender men. SUBJECTS: A sample of 3486 transgender participants who took part in the National Transgender Discrimination Survey in 2008 and 2009. MEASURES: Predisposing, enabling, and health system environment factors, and delayed needed health care. RESULTS: Overall, 30.8% of transgender participants delayed or did not seek needed health care due to discrimination. Respondents who had to teach health care providers about transgender people were 4 times more likely to delay needed health care due to discrimination. CONCLUSIONS: Transgender patients who need to teach their providers about transgender people are significantly more likely to postpone or not seek needed care. Systemic changes in provider education and training, along with health care system adaptations to ensure appropriate, safe, and respectful care, are necessary to close the knowledge and treatment gaps and prevent delayed care with its ensuing long-term health implications

Discrimination and Delayed Health Care Among Transgender Women and Men: Implications for Improving Medical Education and Health Care Delivery

BACKGROUND: The transgender community experiences health care discrimination and approximately 1 in 4 transgender people were denied equal treatment in health care settings. Discrimination is one of the many factors significantly associated with health care utilization and delayed care. OBJECTIVES: We assessed factors associated with delayed medical care due to discrimination among transgender patients, and evaluated the relationship between perceived provider knowledge and delayed care using Anderson\u27s behavioral model of health services utilization. RESEARCH DESIGN: Multivariable logistic regression analysis was used to test whether predisposing, enabling, and health system factors were associated with delaying needed care for transgender women and transgender men. SUBJECTS: A sample of 3486 transgender participants who took part in the National Transgender Discrimination Survey in 2008 and 2009. MEASURES: Predisposing, enabling, and health system environment factors, and delayed needed health care. RESULTS: Overall, 30.8% of transgender participants delayed or did not seek needed health care due to discrimination. Respondents who had to teach health care providers about transgender people were 4 times more likely to delay needed health care due to discrimination. CONCLUSIONS: Transgender patients who need to teach their providers about transgender people are significantly more likely to postpone or not seek needed care. Systemic changes in provider education and training, along with health care system adaptations to ensure appropriate, safe, and respectful care, are necessary to close the knowledge and treatment gaps and prevent delayed care with its ensuing long-term health implications

Assessment of the Efficiency of Tobacco Cessation Counseling in Primary Care

Clinical Practice Guidelines for Treating Tobacco Use and Dependence advocate for using counseling targeted at tobacco users\u27 motivation to quit during each office visit. We evaluate tobacco use screening and counseling interventions delivered during routine periodic health examinations by 44 adult primary care physicians practicing in 22 clinics of a large health system in southeast Michigan. 484 office visits were audio-recorded and transcribed. For this study, current tobacco users (N = 91) were identified using pre-visit surveys and audio-recordings. Transcripts were coded for the delivery of tobacco-related counseling interventions. The extent to which counseling interventions were used and/or targeted to the patients\u27 readiness to quit was the main outcome measure. The majority of tobacco users (n = 77) had their tobacco use status assessed, and most received some sort of tobacco-related counseling (n = 74). However, only 15% received the recommended counseling targeted to their readiness to quit. On the other hand, 19% received less counseling than recommended given their readiness to quit, 7% received only nonindicated counseling, and 59% received nonindicated counseling in addition to indicated counseling. Results illustrate physicians\u27 commitment to cessation counseling and also identify potential opportunities to improve the efficiency of tobacco-related counseling in primary care

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Primary care clinicians\u27 willingness to care for transgender patients

Transgender patients report negative experiences in health care settings, but little is known about clinicians\u27 willingness to see transgender patients. We surveyed 308 primary care clinicians in an integrated Midwest health system and 53% responded. Most respondents were willing to provide routine care to transgender patients (85.7%) and Papanicolaou (Pap) tests (78.6%) to transgender men. Willingness to provide routine care decreased with age; willingness to provide Pap tests was higher among family physicians, those who had met a transgender person, and those with lower transphobia. Medical education should address professional and personal factors related to caring for the transgender population to increase access